FORMAT FOR PERIODIC QUALITY ASSURANCE TEST REPORT FOR MAMMOGRAPHY

EQUIPMENT
(Periodic Quality Assurance shall be carried out at least once in two years and also after any repairs
having radiation safety implications)

A. DETAILS OF THE DIAGNOSTIC X-RAY EQUIPMENT

1 Name of the Institution and City

2 Type of Equipment
3 Model Name
4 Name of the Manufacturer
5 Name(s) of Person(s) testing the equipment
and Name of Supplier/Service Agency
6 Dates and Duration of the Tests

B. SUMMARY OF RADIATION SAFETY PERFORMANCE TEST REPORT:

:

Sr. Parameters tested Specific Measured Tolerance Remarks

No values values
1. Accuracy of Operating Potential ± 1 kV
2. Accuracy of Timer % Error < 10 %
3. Linearity of tube current (CoL) CoL< 0.1
4. Reproducibility of output (CoV) CoV < 0.05
Radiation Leakage level from X
5. < 0.02 mGy in one hour
Ray tube housing ___ kV &__mA
Tolerance :
First HVL at 30 kVp ≥
0.3 mm Al
Total Filtration
6. First HVL at 40 kVp ≥
(Measurement at maximum kV)
0.4 mm Al
First HVL at 50 kVp ≥ 0.5
mm Al
> 4 fibers
7 Performance of imaging phantom > 3 calcification
> 3 masses must be visible

I hereby undertake that all the information provided above is correct and in accordance with the detailed Quality
Assurance Report enclosed herewith.

Place: Signature:
Date: Name of the Service Engineer:
Name of Supplier/Service Agency:
Seal of Supplier/Service Agency:

#Signature of Institution’s Representative:

Name of Institution:
Seal of the Institution:

# Quality Assurance Tests Report shall be signed by Institution’s Representative and duly stamped by the
User’s Institution.
 2.ACCURACY OF OPERATING POTENTIAL/ACCURACY OF TIMER

Applied Set Measured values

kVp tim mA stations
e mA station -1 mA station -2 Av. kVp Observed Remarks
(s) Time (s)
kVp Time (s) kVp Time (s)

(Maximu
m)

Tolerance for kVp :  1 kV

Tolerance for irradiation time :  10 %
*FDD stands for focal spot to detector distance

3. LINEARITY OF mA/mAs LOADING STATION :

Operating parameters
FDD(cm)

FDD(cm) 100 kV Time

mA Output (µGy) Average µGy /mAs Coefficient of Remarks

Range (µGy) ( X) Linearity
(CoL)
Reading 1 Reading 2

Tolerance: Coefficient of Linearity  0.1

4. TOTAL FILTRATION AND ALUMINIUM EQUIVALENCE OF THE COMPRESSION

DEVICE

i) Molybdenum target, Beryllium window or Rh/Rh Rh or W/Al Rh

Added filter thickness = --------- mm Molybdenum

Operating mAs Added filter (mm Al) HVT

Potential Compression mm Al
Device
0.0 0.1 0.2 0.3 0.4 0.5
Result: The HVT of the unit is =_______________mm of Al for -- kVp
Recommended Value: First HVL at 30 kVp ≥ 0.3 mm Al
First HVL at 40 kVp ≥ 0.4 mm Al
First HVL at 50 kVp ≥ 0.5 mm Al

Added filter thickness =-------------mm Molybdenum/Aluminium/Rhodium

5. REPRODUCIBILITY OF RADIATION OUTPUT:

Applied mAs Output (µGy) Average Coefficient of Remarks

kV 1 2 3 (X) Variation (CoV)

Tolerance : COV  0.05

6. RADIATION LEAKAGE LEVELS AT 5 cm FROM THE EXTERNAL SURFACE OF X-RAY

TUBE HOUSING

Operating parameters:

Distance from the 100 kVp (Max) mA Time(s)

focus (cm)

Location Exposure level (mGy/hr or mR/hr) Workload Result

(at 1.0 m Maximum radiation
from the Left Right Front Back Top leakage at 5cm from
focus) the external surface of
X-ray tube housing
Tube 40 mAmin … mGy in 1 hr
in one
hour
Tolerance The leakage radiation averaged over an area of 10 cm2, with no linear dimension greater than 20
cm and located at 5 cm from any point on the external surface of X-ray tube housing does not
exceed 0.02 mGy in one hour.

Max leakage = 40 mAmin in one hour X ----Max leakage mR/hr

60 X -----mA used for measurement

7. IMAGING PERFORMANCE EVALUATION:

Equipment Used: Mammography Imaging Phantom

Sr. Name of the object Number of object visible Tolerance ( Number of object clearly
 No. in Mammography in the film exposed with visible in the film at an average glandular
phantom Mammography dose less than 3 mGy
Phantom
1. Fibers >4 fibers must be clearly visible
2. Micro >3 Micro calcification must be clearly visible
Calcification
3. Masses > 3 masses must be clearly visible

Details of Radiation Protection Survey of the installation

Date of radiation protection survey:

Whether radiation survey meter used for the survey has valid calibration certificate: Yes/No
Equipment Setting:-
Applied Current (mA):
Applied Voltage (kV):
Exposure time(s):
Workload:
Provide the measured maximum radiation levels (mR/hr) at different locations

Location Max. Radiation level (mR/hr)

Control console(Operator Position)
Outside patient entrance door
Behind Windows (if applicable)
Patient Waiting Area

Maximum Radiation level/week (mR/wk) = ----- mAmin/week X ----Max. radiation level (mR/hr)
60 X -----mA used for measurement

Permissible limit: For location of Radiation Worker: 20 mSv in a year (40 mR/week)
For Location of Member of Public: 1 mSv in a year (2mR/week)